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Objective: To measure and compare the accuracy of 4 different clinical methods in the diagnosis of melanoma in situ of the nail matrix among dermatologists with different levels of clinical experience. Design: Twelve cases of melanonychias (5 melanomas and 7 nonmelanomas) were presented following 4 successive steps: (1) clinical evaluation, (2) evaluation according to the ABCDEF rule, (3) dermoscopy of the nail plate, and (4) intraoperative dermoscopy. At each step, the dermatologists were asked to decide if the lesion was a melanoma. Setting: The test was administered at 2 dermatological meetings in 2008. Participants: A total of 152 dermatologists, including 11 nail experts, 53 senior dermatologists, and 88 junior dermatologists. Main Outcome Measures: The answers were evaluated as percentage of right answers for each diagnostic step according to the different grade of expertise. Differences among the percentage of right answers in the different steps were evaluated with the z test at a 5% level of significance. The agreement was investigated using Cohen κ statistic. Results: The only method that statistically influenced the correct diagnosis for each category (experts, seniors, and juniors) was intraoperative dermoscopy (z test; P<.05). Cohen κ statistic showed a moderate interobserver agreement. Conclusions: Overall accuracy of dermatologists in the diagnosis of nail matrix melanoma in situ is low because the percentages of physicians who indicated the correct diagnosis during each of the first 3 clinical steps of the test ranged from 46% to 55%. The level of expertise did not statistically influence the correct diagnosis. [ABSTRACT FROM AUTHOR]

This article presents two case-reports of seborrheic keratosis, and considers the potential difficulties found in the differential diagnosis of melanoma and seborrheic keratosis. In both cases, the histologic examination demonstrated pigmented basaloid cell nests, which are typical of clonal seborrheic keratosis and responsible for globule like images. The absence of dermoscopic criteria for seborrheic keratosis, together with the presence of dermoscopic structures simulating criteria for melanocytic lesions, may induce false diagnosis of these lesions. It is a rare event, and the presence of globule like structures make diagnosis even more difficult.